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Teaching in the Emergency Department

A self-guided multimedia curriculum.
by

Ben Schnapp

on 16 June 2016

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Transcript of Teaching in the Emergency Department

Teaching in the
Emergency Department

Teaching Tricks
One Minute Preceptor
SPIT
SNAPPS
Aunt Minnie
Questioning
Modeling Problem Solving
Bedside Teaching
Activated Demonstration
SNAPPS
S
ummarize the case
N
arrow the differential
A
nalyze the differential
P
robe the preceptor
P
lan management of problems
S
elect an issue for self-directed learning
Questioning
Recall
Analysis/Synthesis
Application
Self-Assessment
Aunt Minnie
Ask the learner to see the patient and return with the DIAGNOSIS ONLY.

Discuss after both seeing the patient how they arrived at that conclusion.
SPIT
S
- What is the most Serious possible diagnosis?
P
- What is the most Probable diagnosis?
I
- What is the most Interesting possible diagnosis?
T
- What is the most Treatable possible diagnosis?
What are the Treatments for the above diagnoses?
Recall
What are the three most common causes of cholecystitis?

What is this patient's bilirubin?
Analysis/Synthesis
Why do you think that diagnosis is most likely?

How do you think those symptoms relate to one another?
Define the goals

Tell learners your goals

Ask learners for their goals
-What do you want them to learn?
-How will they learn it?

Example:
I would like my medical student to improve their differential diagnosis through use of the SNAP technique.
Define the goals
-"My goals for you are..."
-Be specific and clear
-Tell them the relevance of goals

Example:
My goal for you today is a more concise H&P which will help you
work more efficiently in the ED.
Tell learners your goals
Goal Setting
Ask learners
their goals
Example:
Is there anything you've been struggling with that you'd like to work on today?
The RIME Model
Identify their level, help them move up.


R
eporter
-Tells you relevant facts
I
nterpreter
-Generates a ranked differential
M
anager
-Executes treatment plans
E
ducator
-Can teach others about similar situations
Adult Learning Theory
Adults learn best when instruction is....
-Relevant
-Problem-centered
-Experience-oriented
-Active
-Safe
-Followed by feedback
For more please see:
http://goo.gl/cIs5BE
Application
How will you treat this patient's pain?

How will you know when you've confirmed your diagnosis?
Self-Assessment
How would you handle this patient differently if you could do it again?

How well do you think that you understand DKA?
Tips
-Wait for answers - up to 10 second before chiming in (Awkward silence is your friend).

-Use open-ended questions when possible, or follow up yes/no questions ("Why do you think that?)".

-Encourage learner to learner interaction
("What do you think about Steve's answer?")
One Minute
Preceptor
Get a commitment
-What do you think is going on?
Probe for supporting evidence
-What lead you to that conclusion?
Teach general rules
-When this happens, do this...
Reinforce what was good
-You did a nice job with...
Correct mistakes
-Next time this happens, try this...
For more information:
A Five-Step "Microskills" Model Of Clinical Teaching
http://www.jabfm.org/content/5/4/419.full.pdf
Feedback
Private setting
Allow learner to share their thoughts
Share your perspective
Link to their goals
Compare to their self-assessment
Set new goals
Summarize
For more information:
http://jama.jamanetwork.com/
article.aspx?articleid=387652
Structuring a session
Feedback
Well-timed
Expected
Nonjudgmental language
Based on first-hand data
Small amounts at a time
Limited to fixable behaviors
Specific items, not generalizations
Focused on decisions/actions, not assumed interpretations
Guidelines
Introduction
Example
Example
Example
Example
Example
Bedside Teaching
Example
Modeling Problem Solving
Demonstrate good clinical reasoning
Take learner through your own process
-Read triage note, vitals
-Look at old charts
-Examine results
Verbalize every step of your thinking
-Why you did some things and not others
Activated
Demonstration
Give learner an assignment
-"Watch me while I..."
Activate the learner
-"What did you see?"
Discuss what was taught
-"One thing to notice was..."
Assign additional practice/study
-"Now you try it..."
Relevant
Problem-Centered
Experience-Oriented
Active
Safe
Followed by feedback
Example
Social Media
Best practices for social media and blogging.
Podcasting
Green GM, Chen EH. Top 10 ideas to improve your bedside teaching in a busy emergency department. Emerg Med J 2015 Jan;32(1):76-7.
http://goo.gl/F5WZgK
http://new.livestream.com/iTeachEM/events/3767701/videos/76384148
More on giving feedback
http://new.livestream.com/iTeachEM/events/3767701/videos/76384148
Simulation
How to run a simple debriefing session.
Simulation
Managing difficult learners during a debrief
Simulation
-Choose/create a case with clear learning objectives
-Set expectations appropriately (realism, confederates, confidentiality)
-Run the case
-Debrief the case and emphasize learning points
-Most important part by far!
Simulation
Choosing a case

A great library of cases:
http://www.emedu.org/simlibrary/
Simulation
An example pre-briefing session prior to the case
For more information
Simulation debriefing: http://iteachem.net/2013/12/hart-simulation-debriefing/

Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc 2007;2:115– 25.
Link: http://goo.gl/XKDkCK

Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin. 2007 Jun;25(2):361-76
Link: http://goo.gl/nqInZu

Raemer D, Anderson M, Cheng A, Fanning R, Nadkarni V, Savoldelli G. Research regarding debriefing as part of the learning process. Simul Healthc 2011;6:s52-7.
Link: http://goo.gl/56qOhP
Lecturing
Preparation
Creating the visuals
Delivering the lecture
Reflection and improvement
How to give a great talk
Preparation
What does your audience want?
Know your topic inside and out
Read, read, read
Slim the focus of your talk
Articulate the 2-3 take home points
Tell a story with your narrative
90% of the work should be here
Visuals
Pick an appropriate format
-PowerPoint, Prezi, whiteboard, nada
Lay out goals at start
Keep visuals uncluttered
As few words as possible
Make things surprising/exciting
Delivery
Know the location
Get there early
Go slow
Don't panic
Start with a bang
Stay enthusiastic
Don't apologize
Practice, practice, practice
Have fun
-Can express ideas without fear of judgement from teacher or peers
-Participatory
-Learner must be involved, not sitting on sidelines
-Autonomy is best
-Questions appropriate for level can help with this
-What sorts of things do they already know/have they already seen that relate to this?
-Approach to problem more important than solution
-Requires the learner to reason through a problem
-Relates to a patient they have seen/experience they had/fact they learned
-Learner's goals are most important - what do they want to know?
-Should relate to goals and learners self-assessment of performance
-Should be timely and objective
Reflection
Lecture is not over once given
What questions did the audience have?
What went well/less well?
Can ask audience for evaluations
What was unclear?
What parts bored the audience?
Make adjustments for next time
Morning Report
Demystifying Morning Report: How to Conduct a Stimulating Morning Report

http://goo.gl/214THb
For more
50 pearls of lecturing by Dr. Gus Garmel:
http://www.aliem.com/be-a-great-speaker-10-practical-pearls-part-1-of-5/
Start Here!
Why learn to teach?
Rewarding, challenging, fun!
Makes the interaction faster, more efficient
-Can be hard to do correctly without skills
Improves your own understanding of topics
Give back to the medical community
-Improve quality of care for future patients
Necessary part of academic medicine

Social Media
Interact with your followers
Promote other - retweet!
Ask questions and engage followers
Ensure content is high quality
Stay positive
Limit self-promotion/spam
Stay focused on your area of interest
Keep tweets short and simple
Use images when possible
For more information:
http://blog.klout.com/2013/09/highly-effective-twitter-users/
A basic how to
Procedures
Demonstrate the skill
Deconstruct the steps
Verify comprehension
-Learner talks through procedure
Learner performs procedure
Guided practice
-Can use simplified models
Birnbaumer, D. M. Teaching Procedures: Improving “See One, Do One, Teach One”. CJEM, 2011;13(6):390-394. http://goo.gl/NXMZdP

Lake FR, Harndorf JM. Teaching on the run tips 5: teaching a skill. Med J Aust 2004;181(6):327-328

Walker M, Peyton JWR. Teaching in theatre. In Peyton JWR editor. Teaching and learning in medical practice. Rickmansworth. UK, Manticore Europe, Ltd, 1998:171-180
Further reading
Feedback
Beyond "Great Job"
Procedures
Principles and how to teach them
End Here!
Using the techniques defined here, you should now be able to effectively integrate a variety of teaching techniques into your education practice in the emergency department.

Test your knowledge here: http://goo.gl/ki8Thv

Evaluate the course here: http://goo.gl/ayyYwf

Objectives
-Understand the principles by which adults learn best
-Be able to set up, execute and conclude an effective learning session
-Acquire new techniques for engaging learners while working in a busy emergency room
-Learn tips and tricks for effective teaching using a variety of methods, including lecture, simulation and podcasting.
Procedures
A 3 step approach
Avoid being this guy!
How to use
-The presentation will now stop moving
automatically.
-Use the mouse to zoom in and out on the various sections.
-The videos may take some time to load - be patient
-This presentation was meant to be explored at your own pace, in whatever order is of interest to you.
-When you are finished, click on the "End Here" circle to test your knowledge and evaluate the course.
For more reading:
Rogers RL, et al. Practical Teaching in Emergency Medicine. Wiley-Blackwell. 2009.
For More
For More
Patients like it, learners like it - do it!
Choose an appropriate patient
-Interesting exam finding, history NOT x-ray finding
Obtain consent from patient
Establish safe environment
-OK to ask questions, involve patient
Avoid jargon, scary phrases
-"cancer" "negative test"
Model skills
Demonstrate skills
-exam maneuvers, reassuring phrases/gestures, professionalism
Debrief - emphasize learning points
For more:
Ramani S. “Twelve tips to improve bedside teaching.” 2003. Med Teach. 25(2): 112-115.
Debriefing tips
-Be curious - learners have a lot of interesting insights!
-Don't make assumptions - you never know why learners may have done something
-Listen actively - incorporate what learners are saying into your discussion
-Be yourself - don't get tied into scripted debriefing
-Pick your spots - teamwork is a better debriefing topic than technical skills
For more
http://icenetblog.royalcollege.ca/2015/02/10/effective-debriefing-tips-for-simulation-based-medical-education/
Full transcript